When your toddler DOESNT TALK

There is nothing simple about speech,and there is nothing simple about speech delaystarting with the challenge of diagnosing it.

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How to cope with speech delay in your child
There is nothing simple about speech,and there is nothing simple about speech delaystarting with the challenge of diagnosing it. Every paediatrician knows the frustration of trying to quantify the speech and language skills of a screaming toddler. How many words can he say? Can she put two or more words together into a sentence? Can people besides you understand him when he talks? Questions like these,put to the parents,are quick and somewhat crude yardsticks.
Crude or not,the assessment is crucial: the earlier it is made,the earlier the speech-delayed child can get some help,and the earlier the help,the better the prospects.

Children within the first year start to understand much of what they hear around them, said Dr Diane R. Paul,director of clinical issues in speech-language pathology at the American Speech-Language-Hearing Association. One-year-olds,she continued,start to use single words and follow simple directions and point to body parts and listen to simple stories. By about two,they start putting words together; by three,they should be using sentences of three words at the very minimum.

The early utterances may be simple,but what produces them is very complex. When a child is not meeting those milestones,there can be a multitude of reasons. Dr James Coplan,a neurodevelopmental paediatrician in Rosemont,Pennsylvania,who is also the author of Making Sense of Autistic Spectrum Disorders Random House,2010,says he looks at speech delay in a very broad context,from cognition to communication. Is it purely a problem with speech and language,or is there some more global delay? Has something gone awry in the childs social connections?

The first question to ask is whether the child can hear. Nowadays,all newborns have their hearing screened before they leave the nursery,but later testing can pick up progressive or acquired hearing loss.
Next question: What about the rest of the childs development? Speech and language delay can be one way parents and paediatricians first notice more global developmental delay.

Youll see delayed receptive language,delayed use of visual skills like pointing,adaptive skills like using a spoon or using a crayon, Dr Coplan said. An 18-month-old not following commands,not using a spoon to dig with,now youre looking at global delay.

Speech and language issues can also be early clues to neurodevelopmental disorders,including various forms of autism. Not all children with autism will have delayed speech,though often they are not using their words to communicate; such a child may have memorised the alphabet,Dr Coplan said,but without ever learning Mama or Dada.

If the childs hearing and development are fine,one more question to consider is environment. Is anyone talking to this baby? Is something getting in the waymaybe an exceptionally chaotic household,maybe a severely depressed parent? Speech and language development requires stimulation.

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As a primary care paediatrician,I have not always managed brilliantly with parents. I once took care of a little boy about whom I worried more and more. In the exam room,he seemed without normal communication skills; I was increasingly sure that he was on the autistic spectrum.
I didnt think he was really learning words,but I worried much more because as far as I could tell,he never made eye contact,never responded in any clear way to anything his parents said or did,because he seemed disconnected in some fundamental way.

His parents shrugged off my concerns and refused all referrals. When he was home with his grandmother,they insisted,he was able to communicate perfectly. He didnt need any help.
In that case,I had the diagnosis right,but my own communication skills were not up to the challenge. And then there were the parents I reassured: she may not be talking as much as her sister did at that age,but she is saying much more than the minimum for a two-year-old,she understands everything you say to her and she can follow complex commands. Lets wait and watch,lets give her time. Did I get that one right?

Paediatricians are reminded again and again not to be casual about delays in speech and languagenot to shrug and say boys just talk later than girls,or younger siblings talk later than older siblings. Such factors may contribute to normal variation,but they shouldnt be used to explain why a child doesnt meet essential milestones.
And as every paediatrician knows,the real stalwarts in this storyand the real expertsare the speech and language pathologists.

Dr Paul offered general tips to parents who want to enhance their childrens speech and language skills: Talk to your child about what theyre focused on. Read to your child often. If theyre in a bilingual home,speak to the child and read to the child in the language that youre most comfortable with. Speak clearly and naturally and use real words. Show excitement when the child speaks.
And listen to what your child is telling you.
_Perri Klass,NYT